For patient encounters provided solely by the APP, column A would be followed. APPs would bill the visit under their own NPI if the APP evaluated, diagnosed, and treated the patient. In addition, if the attending physician briefly visited the patient during the appointment but did not perform and document a portion of the physical examination and/or face-to-face medical decision-making, column A would be followed. If, however, the APP and attending physician both evaluated the patient in provider-based clinics and the attending physician performed and documented a portion of the physical examination and/or face-to-face medical decision-making, column B would be followed. This visit would be billed under the attending physician's NPI, but the APP would receive credit as the performing provider. This algorithm (column B) follows Medicare-shared guidelines.
The inpatient algorithm follows similar principles, except the APP was considered the service provider (provider who examined the patient) rather than the scheduling provider (provider in which the patient is scheduled to see in an outpatient setting) in a shared visit (column B).
Special considerations needed to be taken for procedures, admission history and physical notes, and discharge summaries to comply with the Centers for Medicare and Medicaid Services (CMS). This ensured that the documentation rules implemented complied with federal and state statutes, as well as hospital rules, regulations, and bylaws.
Certain departments were exempt from using the proposed billing algorithm. Pediatric APPs were exempt because they receive lower reimbursement rates when practicing in subspecialties. Because the ED has its own coding system, this group of APPs also was excluded during the first implementation phase.
After the algorithms were written, they were tested and retested multiple times. This involved running different scenarios to determine whether the bills were being appropriately submitted under either the APP (column A) or the attending physician (column B) and whether the APP was recognized as the author or performing provider/service provider (column B). APPs mostly billing shared visits under the attending physician were asked to follow the algorithm for 1 month. Data were compiled before and after implementation and were evaluated for inconsistencies.
After approval was obtained from senior leadership, a plan for the educational rollout was developed. This involved providing a number of mandatory educational sessions for the APPs by the directors of advanced practice. Representatives from compliance and the EMR also were present during these sessions to answer questions. In addition to slideshow presentations, a recorded presentation narrated by the directors of advanced practice was placed in MyQuest, the campuswide learning management system that provides compliance training and learning opportunities for providers and employees. The implementation date, 2 months later, coincided with the beginning of fiscal year (FY) 2018 and a new funds flow model of compensation for the healthcare system. In this model, each department would receive payment based on the number of work relative value units (wRVUs) generated by providers in the department. wRVUs, a national standard used for measuring productivity, budgeting, allocating expenses, and cost benchmarking, are a measure of value used in the Medicare reimbursement formula for provider services. The dollar per wRVU for various subspecialties was determined using national standards (a combination of MGMA and United Health Care data) for APP and physician productivity and compensation. The goal of implementing this funds flow model was to align revenues and costs for more informed decision-making, and to create cash on hand for outreach expansion.
Initially, compliance monitored progress of APPs using the new APP billing algorithm in multiple practice areas including inpatient and outpatient locations on a weekly basis for 6 weeks. The review of 1,183 charts was to validate both APP independent billing and shared visit charges that contained the APP as performing/service provider and the attending as the billing provider. The compliance review was agnostic to insurance carrier or clinic location (excluding the ED locations and all pediatrics).
Compliance performed audits, gave feedback to the providers, and after 5 weeks, the error rate decreased 36%. Ongoing monitoring is in place to ensure continued improvement. Inconsistencies identified in the compliance monitoring program suggested that APPs were not following outpatient/inpatient algorithms when seeing patients independently. Any deviation from the billing algorithm would not capture the APP as the performing/service provider and/or billing provider.
Inconsistencies identified by the attending providers were using incorrect attestations to the APP note as well as inconsistencies in documentation practices. This was mostly a result of the use of incorrect resident attestation verbiage or incomplete documentation of the physical examination or medical decision-making.41 Direct communications were sent via compliance to several providers to correct these errors.
After collecting 12 months' of APP wRVU data, comparisons were made with baseline wRVUs and collections for FY 2017 versus FY 2018 (Table 2). Data samples were examined from outpatient clinics in primary care, specialty medicine, and surgical teams. As suspected, the APPs' wRVUs and collections rose dramatically in all groups. This increase was statistically significant in all four groups (P < .05, CI 95%).
When focusing specifically on the general internal medicine group, the APPs' wRVUs increased by 7,745 (P = .04, CI 95%). After group adjustments for new hires, wRVUs for the APPs increased 608%. In addition, the wRVU for attending physicians in internal medicine increased 3%. For the team of APPs and attending physicians in internal medicine, the overall wRVU increased 24%. Collections also increased for both groups. Attending physicians in internal medicine had a 5% increase in collections. APP collections increased 769%; the team total for internal medicine increased 29% after adjusting for new hires (Table 2).
Improvements as a result of this quality improvement project
As seen by these results, the new APP billing algorithm encouraged improved utilization and efficiency of the APP/physician team. Compliance errors were reduced among APPs and attending physicians. From the financial perspective, the APP billing algorithm attributed each provider's wRVU contribution to productivity. Before implementation of a standardized billing algorithm, wRVU inflation occurred for the attending physicians because APPs billed under the physicians' NPIs. However, when APPs began to bill under their own NPIs, the physicians' wRVUs continued to increase. Accurate attribution of data now can help project APP/physician staffing needs, determine clinic space needs, and calculate appropriate support staff levels. From a retention perspective, the algorithm allows a practice or department to use these data to develop potential incentive programs to reward individual high performers, APP-physician teams, and successful departments in a healthcare system. Most importantly, the APP algorithm drives increased opportunities to access care through improved work flow efficiencies.
As expected, a number of issues needed to be addressed after implementation of the new APP billing algorithm. One concern during a shared visit was that attending physicians were not able to view their patients once the scheduling provider was changed to the APP. When the APP changed encounter provider, the patient was removed from the attending physician's schedule. To resolve this issue, the buttons in the EMR needed to be reprogrammed to reflect shared visit and APP visit. APPs would no longer need to change the scheduling provider to themselves. This let the patient remain visible on the attendings' schedules.
Another concern revolved around return communication to the referring provider after a consult was completed. If the APP was the service provider, all letters to the referring providers generated the APP's signature rather than that of the attending physician. During a shared visit, attending physicians requested that referring providers receive communication from the attending physician. Once the shared visit and APP visit button was developed, this issue resolved.
On the inpatient side, a major challenge of the algorithm occurred when the note was sent from the APP to the attending physician for cosignature. In the EMR, after the APP sent the chart to the attending for cosignature, if the attending changed the service provider field, the system would not recognize the APP as part author. In this case, the APP would not receive credit as performing provider. These vagaries of the EMR confounded the ability to capture the APP as the service provider. After testing and retesting, these variations were corrected so that the service provider field could be locked by the service provider, even when encounters required cosignature by an attending physician. To avoid this compliance error, after the APP entered her or his name in the service provider field, the field would automatically lock so that the attending physician could not change the name.
Need for the development of a new financial dashboard
The new APP billing algorithm captures more accurate billing data to recognize APPs as performing and/or billing providers. However, a revision in the monthly APP provider financial dashboard was necessary to provide a more detailed, user-friendly APP record for APP providers and departments to access. The financial dashboard was developed by the directors of APP practice and built in Tableau Server Version 10.5.3–10500.18.0404.1406, a proprietary software used at MUSC, with the assistance from internal IT solutions consultants (Figure 3). The objective of the financial dashboard was to let providers and administrators clearly identify APP and attending physician productivity.
The financial dashboard includes revenue cycle, access (PATH), and the Clinician and Group Consumer Assessment of Healthcare Providers and Systems scores. These metrics, specific to the organization, let providers assess their productivity and patient satisfaction scores.
The revenue cycle tab attributes wRVUs by APP independent visits (APP is both the billing and performing provider) and by APP/attending physician shared visits (APP is the performing provider and the attending physician is the billing provider). Other revenue cycle metrics include monthly charge lag (number of days in which a chart is signed and closed by the billing provider), new patient billed visits, and total number of patient visits (including preoperative and postoperative). The APP and/or administrator can view current month or 13-month wRVU history, top service codes billed by the specific provider, total payer mix (breakdown of patient's insurance type), and the wRVUs generated during shared visit encounters with a particular attending physician. On the access (PATH) tab, the provider can review variables that affect access on a daily basis and compare them with the past fiscal year. Finally, the patient experience tab lets APPs review patient satisfaction scores.
An organizational plan to standardize billing practices for APPs is necessary in today's changing healthcare environment. The plan should include developing a task force comprising APP representation, compliance, EMR/IT, and business analytics. This ensures that the standardized billing is built with checkpoints that include updated practice laws, compliance/legal standards, hospital bylaws, and the ability to extract data and reporting metrics. After a task force is in place, assessment must be made of the current state. This includes a first pass of data capture that differentiates between independent APP visits and APP/attending physician shared visits. Next, an evaluation is needed of the actions required when an APP enters a level of service (1 through 5) and visit diagnoses (ICD-10 codes). Finally, a compliance audit is needed on current documentation and billing practices for independent APP visits and APP/attending physician shared visits. When developing the APP billing algorithm, CMS guidelines must be followed. The task force should streamline steps for the APP to follow when billing an independent versus a shared visit in inpatient and outpatient settings. Billing data need to reflect independent versus shared visits. Furthermore, the shared visits should attribute the APP as performing provider and the attending physician as billing provider. The algorithm should outline proper supporting documentation to be completed by the attending physician to meet CMS guidelines.
Next, an educational rollout and go-live date need to be agreed on for key stakeholder groups, including senior leadership, department administrators, physician leaders, compliance managers, EMR educators, attending physicians, and APPs. After education is completed with a go-live date, 6-month and 1-year data reviews including wRVU and collections can be compared with data from before and after implementation of the algorithm. A data review can be run in parallel with monthly compliance audits to ensure proper algorithm use. At 1-year postimplementation, a review of the steps is necessary to refine the algorithm to simplify steps for providers and reduce errors.
As demonstrated by this quality improvement project, buy-in needs to be secured from senior leadership to review current billing practices and data output and will be the impetus to propose standardized billing for APPs. With the APP workforce growing, the implementation of EMR systems, and today's healthcare financial constraints, healthcare systems must standardize their billing practices. All professional services delivered by providers need to be accurately captured by the EMR. This ensures that all professional services delivered by APPs are attributed to the appropriate healthcare provider, despite services billed under the attending physician.42
1. Kurtzman ET, Barnow BS. A comparison of nurse practitioners, physician assistants, and primary care physicians' patterns of practice and quality of care in health centers. Med Care
2. Pittman P, Williams B. Physician wages in states with expanded APRN scope of practice. Nurs Res Pract
3. Timmons EJ. The effects of expanded nurse practitioner and physician assistant scope of practice on the cost of Medicaid patient care. Health Policy
4. Yang Y, Long Q, Jackson SL, et al Nurse practitioners, physician assistants, and physicians are comparable in managing the first five years of diabetes. Am J Med
5. Reimbursement Task Force and APRN Work Group, of WOCN Society National Public Policy Committee, 2011. Reimbursement of advanced practice registered nurse services: a fact sheet. J Wound Ostomy Continence Nurs
. 2012;39(2 suppl):S7–S16.
7. Bauer JC. Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. J Am Acad Nurse Pract
8. Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood)
9. Donald F, Martin-Misener R, Carter N, et al A systematic review of the effectiveness of advanced practice nurses in long-term care. J Adv Nurs
11. Kilpatrick K, Kaasalainen S, Donald F, et al The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review. J Eval Clin Pract
12. Kuo YF, Chen NW, Baillargeon J, et al Potentially preventable hospitalizations in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians. Med Care
13. Lewis SR, Nicholson A, Smith AF, Alderson P. Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database Syst Rev
15. Newhouse RP, Stanik-Hutt J, White KM, et al Advanced practice nurse outcomes 1990–2008: a systematic review. Nurs Econ
17. Stanik-Hutt J, Newhouse RP, White KM, et al The quality and effectiveness of care provided by nurse practitioners. J Nurse Pract
18. Traczynski J, Udalova V. Nurse practitioner independence, health care utilization, and health outcomes. J Health Econ
20. Hooker RS, Muchow AN. Modifying state laws for nurse practitioners and physician assistants can reduce cost of medical services. Nurs Econ
21. Hain D, Fleck LM. Barriers to NP
practice that impact healthcare redesign. Online J Issues Nurs
22. Fairman JA, Rowe JW, Hassmiller S, Shalala DE. Broadening the scope of nursing practice. N Engl J Med
23. Salsberg ES. Is the physician shortage real? Implications for the recommendations of the institute of medicine committee on the governance and financing of graduate medical education. Acad Med
24. Capstack TM, Segujja C, Vollono LM, et al A comparison of conventional and expanded physician assistant hospitalist staffing models at a community hospital. J Clin Outcomes Manage
25. Dhuper S, Choksi S. Replacing an academic internal medicine residency program with a physician assistant—hospitalist model: a comparative analysis study. Am J Med Qual
26. Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. J Hosp Med
27. Singh S, Fletcher KE, Schapira MM, et al A comparison of outcomes of general medical inpatient care provided by a hospitalist-physician assistant model vs a traditional resident-based model. J Hosp Med
28. Buppert C. The pros and cons of mandated collaboration. J Nurse Pract
29. Thrasher C, Purc-Stephenson RJ. Integrating nurse practitioners into Canadian emergency departments: a qualitative study of barriers and recommendations. CJEM
31. Hansen-Turton T, Ritter A, Torgan R. Insurers' contracting policies on nurse practitioners as primary care providers: two years later. Policy Polit Nurs Pract
33. Medicare Payment Advisory Commission. Report to the Congress: Medicare payment to advanced practice nurses and physicians assistants. Washington, DC, 2012.
35. Advanced Practice Registered Nurse Consensus Work Group and National Council of State Boards of Nursing Advanced Practice Registered Nurse Advisory Committee. Consensus model for advanced practice registered nurse regulation: licensure, accreditation, certification, and education. Washington, DC, 2008.
36. Miller M, Snyder M, Lindeke L. Nurse practitioners: current status and future challenges. Clin Excellence Nurse Pract
37. Gadbois EA, Miller EA, Tyler D, Intrator O. Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010. Med Care Res Rev
39. Austria JL. Urging a practical beginning: reimbursement reform, nurse-managed health clinics, and complete professional autonomy for primary care nurse practitioners. DePaul J Health Care Law 17. http://via.library.depaul.edu/jhcl/vol17/iss2/3
. Accessed October 26, 2018.
Keywords:Copyright © 2019 American Academy of Physician Assistants
advanced practice provider; billing; NP; PA; productivity; wRVUs